Sinking Skin Flap Syndrome and Paradoxical Herniation After Hemicraniectomy for Malignant Hemispheric Infarction

Abstract

, MD; the DECIMAL investigators Background and Purpose-"Sinking skin flap" (SSF) syndrome is a rare complication after large craniectomy that may progress to "paradoxical" herniation as a consequence of atmospheric pressure exceeding intracranial pressure. The prevalence and characteristics of SSF syndrome after hemicraniectomy for malignant infarction of the middle cerebral artery are not well known. Methods-We analyzed a prospective cohort of 27 patients who underwent hemicraniectomy for malignant middle cerebral artery infarction. All had a clinical and brain imaging follow-up at 3 months and were followed until cranioplasty. Results-Three of 27 patients (11%) had, at 3 to 5 months posthemicraniectomy, SSF syndrome with severe orthostatic headache as the main symptom. Key Words: complications Ⅲ surgery Ⅲ hemicraniectomy Ⅲ malignant cerebral artery infarction Ⅲ herniation T he syndrome of the "trephined" or the "sinking skin flap" (SSF) syndrome is a rare complication after a large skull bone defect. 1 It consists of a sunken skin above the bone defect with neurological symptoms such as severe headaches, mental changes, focal deficits, or seizures. 1,2 The SSF may progress to "paradoxical herniation" as a consequence of the atmospheric pressure exceeding intracranial pressure and may eventually lead to coma and death.The objective of our study was to determine, in a prospective cohort of malignant infarction of the middle cerebral artery (MCA), the prevalence and characteristics of SSF syndrome and of any radiological sunken skin flap without symptoms after hemicraniectomy. Materials and Methods PatientsAll patients randomized in the surgical arm of DEcompressive Craniectomy In MALignant middle cerebral artery infarcts (DECIMAL), a trial that compared medical treatment and hemicraniectomy in malignant MCA infarction as well as all consecutive patients who had hemicraniectomy for a malignant MCA infarction in our stroke center after the end of DECIMAL inclusion but according to the same criteria, were considered. 3 All surviving patients had at the 3-month follow-up a clinical and brain imaging evaluation (axial and/or coronal fluid-attenuated inversion recovery MRI and/or axial and/or coronal CT scan) and were then followed every 3 months for 1 year. The timing and procedure of cranioplasty were left to the discretion of the neurosurgeon. The study was approved by an institutional ethics committee, and the patient or a close relative gave informed consent. Radiological EvaluationThe following measures were performed by the same neuroradiologist (J.-P.G.): (1) the maximum horizontal surface of the skull was estimated either on axial CT scan or axial fluid-attenuated inversion recovery MRI using the following formula: /4ϫAϫB in which "A" was the maximum distance from the anterior and posterior inner tables of the skull and "B/2" the half-depth to the inner skull surface opposite to the bone flap measured at the midpoint of "A"; (2) the whole surface of craniectomy was estimated either on coronal reformation and ...

Paradoxical herniation after unilateral decompressive craniotomy: a retrospective analysis of clinical characteristics and effectiveness of therapeutic measures

“…It is also known as the "sinking skin flap syndrome" because of the sinking skin flap overlying region of decompressive craniectomy occurred in the subacute phase (36). The syndrome of the trephined is not uncommon following craniectomy with an incidence of 10% in our cohort (13 in 131 patients with decompressive craniectomy), which is consistent with the incidence in other study results that ranged from 7% to 11% (29). The patients presented persistent or orthostatic headaches, dizziness, mood disturbances, and memory difficulties within weeks to months after craniectomy, cerebral metabolism, prevention of cerebral cortical thinning and improvement of cerebral vascular reserve capacities (11,37).…”

“…However, it has been reported (1,13,29,34) that the cranial conversion from a "closed box" to an "open box" affects the balance of pathophysiology, which brings risks. Paradoxical herniation, an unusual complication of cerebrospinal fluid (CSF) drainage in patients with large decompressive █ InTRODuCTIOn T he patient with uncontrollable intracranial hypertension usually undergoes emergency decompressive craniectomy (1,7,14).…”

“…To date, the information on paradoxical herniation as procedural outcomes affecting patient survival and recovery is mostly based on sporadic case reports rather than multi-centered, randomized, controlled clinical trials (1, 13,29,34). Thus, the neurosurgeons need to do further clinical investigation.…”

Comparison of manually shaped and computer-shaped titanium mesh for repairing large frontotemporoparietal skull defects after traumatic brain injury

“…Uncovered pulsating brain is often associated with weakness of limbs and aphasia, and cosmetic abnormalities of the head can also produce feelings of inferiority, anxiety, and even depression in these patients; 5,6,15 these abnormalities are related to the "sinking skin flap" syndrome. 16 Thus, through cranioplasty, patients not only receive a restored physical appearance, but may also regain self-confidence and dignity.…”

Kranioplastik nach supratentorieller dekompressiver Kraniektomie

“…Hinzu kommt das Auftreten unterschiedlicher, oft positions-und mobilisationsdauerabhängiger fluktuierender neurologischer Symptome in zeitlicher Assoziation mit dem Einsinken des Hautlappens, das in der Literatur als "syndrome of the trephined" bezeichnet wird [8,28,37].…”